Schies, Mark rIO`14N OF QUEEVBU9�Y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSHURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director IVGA^j
NamelL�„ /�S Case # 333
Date of Cremation( —/T —Ty
Time Cremation Started
Time Cremation Completed /& !►'L,4 / -L�
Type of Container 4?l?-agel9Pi VI✓ // �'i/ j 7 �/¢y
Remarks :
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ATTACH ALTl'H01MATION FOR CREMATION ANI) DISPOSITION
BOOKLET
HERE NOTICE THIS IS A LEGAL DOCUMENT. IT CONTAINS IMPORTANT PROVISIONS CONCERNING CREMATION.
CREMATION IS IRREVERSIBLE AND FINAL.READ THIS DOCUMENT CAREFULLY BEFORE SIGNING
I/We,the undersigned, ce-,warrant and represent that I/we have the full legal right and authority to authorize the cremation,processing and
disposition of the remains of_ �� �(&; e S (hereinafter referred to as the"Deceased").
Name 6ED-eceased
Date of Death A It) i 9 r J 'rune of Death ❑A.M. ❑P.M.
I/We hereby request and authorize (iA� R# (hereinafter referred to as the"Funeral Home")to
Nameo Funeral Home
take possession of and make arrangements for the cremation of the remains of the Deceased at
(hereinafter referred to as the"Crematory"). Name of Crematory
I/We authorize the Crematory to return the cremated remains of the Deceased to the possession and custody of the Funeral Home. I/we
understand that the services and obligations of the Crematory shall he fulfilled when the cremated remains of the Deceased are returned to
the possession and custody of the Funeral Home. I/We hereby authorize the Funeral Home to arrange for the disposition of the cremated
remains of the Deceased as follows:
Is special handling required? ❑Yes 51 No Describe
Description of urn or container selected: Suitable for shipping: ❑Yes ❑No
❑ Deliver to Cemetery
Name and Address of Cemetery
Release to family
Name of esignated Family Member to Receive Cremated Remains
❑ Scattering at sea by Funeral Home or Funeral Homes agent
❑ Ship via U S Registered Mail*
To: Name: Address:
❑ Other
Funeral Home and Crematory are not responsible for any loss or damage of cremated remains shipped via Registered Mail with the United
States Postal Service.
The authorized
rein shall
cremation
laws ode rulesmregulations g and andon of the remains of the olio ess of the Crematory and Funedral Home, and the following b performed s and c nditions:accordance with all
$ g � , P n'
1. The remains of the Deceased will not he accepted for cremation unless received by the Crematory in a combustible, leak resistant, rigid
cremation container. The Crematory is authorized to remove and dispose of handles, ornaments and any other noncombustible items
attached to the cremation container prior to cremation. In the event the remains of the Deceased are received by the Crematory in a casket
or other container constructed of metal, fiberglass, or other noncombustible materials, I/we authorize the remains of the Deceased to be
removed prior to cremation and placed in a combustible cremation container. I/We further authorize the Funeral Home or Crematory to
make disposition of any such noncombustible casket in any lawful manner it deems appropriate.
2. Mechanical or radioactive devices implanted in the remains of the Deceased (such as pacemakers, etc.) may create a hazard
When placed in the cremation chamber. The Crematory will not cremate any human remains which contain any type of
implanted mechanical or radioactive device. In the event the remains of the Deceased contain such a device, I/we hereby
authorize the Funeral Home, its agents and employees, to remove any such mechanical devices from the remains of the Deceased
prior to cremation, and dispose of such items at its discretion. I/WE HEREBY CERTIFY THAT THE REMAINS OF THE DECEASED
DO = DO NOT Z6 CONTAIN ANY TYPE OF IMPLANTED MECHANICAL OR RADIOACTIVE DEVICE.
Please initial one.
Listed below are all implanted mechanical and radioactive devices which the Funeral Home is authorized to remove from the remains of the Deceased
prior to cremation,and dispose of as indicated:
Description of Implanted Device Disposition
Description of Implanted Device Disposition
If no instruction for disposition is given, such items may be disposed of at the discretion of the Funeral Home.
3. The cremation container containing the remains of the Deceased will be placed in the cremation chamber and will he totally and
irreversibly destroyed by prolonged exposure to intense heat and direct flame. I/We authorize the Crematory to open the cremation chamber
during the cremation process and reposition the remains of the Deceased in order to facilitate a complete and thorough cremation.
4. Certain items, including, but not limited to, body prostheses, dentures, dental bridgework, dental fillings, jewelry, and other
personal articles accompanying the remains of the Deceased, may be destroyed during the cremation process. I/We further
authorize that if any items, other than the cremated remains of the Deceased, are recovered from the cremation chamber, they
may be separated from the cremated remains of the Deceased and disposed of by the Crematory.
5 not limited to hereby ,hinges,latches,thorize the mnailsr Crematory
and prec to separate d remove from the cremation ious metals,and to dispose o{such chamber at noncombustible materials, including, but
6. Following cremation, the cremated remains of the Deceased, consisting primarily of bone fragments, will be mechanically pulverized to
an unidentifiable consistency prior to placement in an urn or other container.
7. Unless an urn or container suitable for shipment is purchased, the Crematory will place the cremated remains of the Deceased in
a container which is not designed for any type of shipment.
0 r .1 _. I-- ___— __ ___,._:___ :- +,. ,,,,.,,.......,,,h+o ill „I 4-ha nmma+Prl mmaina of +h,P T)eneaaed. anv excess cremated
DISPOSITION OF CREMATED REMAINS
I hereby direct Pine View Crematorium to disposq of the cremated
remains as follows :
Mail to
Other arrangements — please specify :
If pulverization of cremate remains is requested, check here
POLICIES, RULES AND REGULATIONS
1 . . The crematorium will be open For cremations 5 days• a week
7 :00 A. M. — 3 : 30 P. M. Monday—Friday. No ' Holidays or Sundays,
arrangements can be made For Saturday. Prearrangements by
telephone for acceptance of remains is necessary.
2. Pine View Crematorium is located on the grounds of the Pine
View Cemetery, Quaker Road, Town of Queensbury.
3. An authorization For cremation properly signed by the nearest
next of kin or other authorized person stating that they do have
the power, -and authority to arrange For the cremation of the
remains and to direct the disposition of the cremated remains,
-that - any personal possessions have either been removed or may be
destroyed and agree to protect , defend and save" harmless Pine
View Crematorium from any and all claims. and demands for loss of
damages which may be made against them by reason of or connected
with the cremation of said remains and/or disposition of said
. remains as directed, whether such claims or demands are, or are
not wholly groundless, false or fraudulent . This authorization
in addition to a regular burial permit must accompany the
remains.
4• ., All,, remains must be encased in a casket or suitable alternate
r container. Caskets and containers must be of combustible
watt�er' �iatl C No styrafoam or plastic_ containers will be accepted.
S:"x The `question relative to cardiac pacemakers must be answered
on`' tlie"'auth'ori`zation to cremate re e remains
form before the will be
` accepted.
-- Unless other arrangements are made the cremated remains w
to the ill
be mailed •via Registered U. S. Mail within three days of cremation
funeral home handling the service. Ther
charge—for- this service. e will boa t2Q), 00
Cremation, Administration Costs and Recording Fe.Chj1d.re.n.,.,.,_(age.. 13 months to 12 years ) ti1 e : -Adult t1� 5. 00
,0. 00 Infants ( stillborn
to 12 month1s )"+-t�0. 00
• TOWN OF QUEENSUURY3
PINE VIEW CEMETERY
A
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (516) Cr�e'mat or i um 745-447'7 or if no answer
Cemetery 745-4476
AUTI•IOIZ I ZAT I ON TO CREMATE
The undersigned requests and authorizes Pine View Crematorium, in
accordance with and subject to its Rules and Regulations to
cremate the remains
of :
(Name) (Sex )
1 S 6-kt S C �Y1 I a
(Street ) - (City ) (Sta e) ( Zip Code )
who died on 1 V day of 19
at -�iJ-,(-L C-!(- pz�i r
(Place) (Address )
Name_ and, . address of nearest living relative or name of person
authorizing cremation :
:(Name) (Address )
Re1ati,oriship to the de eased S �e�
Nance 'of Funeral Home
IMPORTANT:
(`'represent that to the best of my knowledge, the deceased has or
has no pacemaker in his or her body. (Circle One )
I' certify"that I have the full power and •aut:horization to arrange
'f or" the' crematfon of the remains and to direct the disposition of
the' crem;aced ` remains, that any personal possessions have either
been removed or may be destroyed, and agree to protect, defend
"and) saye h"aimless Pine View Crematorium from any and all claims
and'Vem'and'st�for' loss :or damages which may be made against them by
reason of or connected with the cremat.-io.n of said remains as
directed, whether such claims or demands are or are not wholly
groundl'es's';`!_'fals'e or 'fraudulent .
Witness ) (Address )
(Signature of Relative or Legal Rep. and Address)
Signed on this date : 13 "j r